PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post...

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STATE OF LOUISIANA DEPARTMENT OF JUSTICE CRIMINAL DIVISION PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone: (225) 326-6210 Fax: (225) 326-6295 Attorney General Buddy Caldwell

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Page 1: PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone:

STATE OF LOUISIANA DEPARTMENT OF JUSTICE

CRIMINAL DIVISION

PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE

MEDICAID FRAUD CONTROL UNITPost Office Box 94005

Baton Rouge, Louisiana 70804-9005Telephone: (225) 326-6210

Fax: (225) 326-6295

Attorney General Buddy Caldwell

Page 2: PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone:

MEDICAID FRAUD CONTROL UNITS (MFCU)

•investigate and prosecute Medicaid fraud as well as patient abuse and neglect in health care facilities•operate in 49 States and in the District of Columbia.•Forty-four of the MFCUs are located as part of Offices of State Attorneys General•6 are in other State agencies

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OIG certifies, and annually recertifies, each MFCU OIG collects information about MFCU operations and

assesses whether they comply with statutes, regulations, and OIG policy

OIG also analyzes MFCU performance based on 12 performance standards and recommends program improvements where appropriate

http://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/index.asp

MEDICAID FRAUD CONTROL UNITS (MFCU)

Page 4: PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone:

MFCUs must be "single, identifiable" entities professional staff are required to work full-time on MFCU duties.

States administer the MFCUs they are jointly funded on a matching basis with the Federal Government.

(The Federal Government pays 90 percent of a Unit's costs for the first 3 years of a Unit's operation and 75 percent for subsequent years; the States pay the remaining portion.)

MFCUs operate on an interdisciplinary model must employ investigators, auditors, and attorneys.

The MFCUs are required to have statewide authority to prosecute cases or to have formal procedures to refer suspected criminal violations to an office with such authority.

The MFCUs' investigative authority extends to Medicaid-funded facilities and to "board and care" facilities that do not receive Medicaid funding. OIG, or another agency's Inspector General, may in some circumstances permit the Units to investigate fraud in Medicare or other Federal programs.

MEDICAID FRAUD CONTROL UNITS (MFCU)

Page 5: PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone:

MFCU FEDERAL FY 2012

Combined Federal and State grant expenditures totaled $217.3 million $162.9 were Federal funds

Collectively, all 50 MFCU’s Employed 1,901 individuals Conducted 15,531 investigations

11,660 were Medicaid fraud related 3,871 were patient abuse cases

1,359 individuals were indicted or charged criminally 995 criminally charged with fraud 364 criminally charged with abuse

1,337 convictions were reported 982 related to Medicaid fraud 355 related to patient abuse

Civil judgments and settlement totaled 823

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MFCU FEDERAL FY 2012

Collectively, the MFCU’s reported $2.9 billion in recoveries* Translates into a return on investment of $13.48 per $1

expended by the Federal Government 747 of the 3,131 exclusions reported to HHS-OIG

were based on referrals made by MFCU’S

*recoveries are defined as monies that defendants are required to pay as a result of a settlement, judgment or pre-filing settlement in criminal and civil cases and may not reflect actual collections

Page 7: PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone:

LOUISIANA MFCU

Created in 1978 Convicted hundreds of persons for program

violations and recovered millions of tax dollars The unit has twice been recognized as the

number one MFCU in the nation by the United States Department of Health and Human Services, Office of the Inspector General.

National Association of Medicaid Fraud Control Units (NAMFCU)

www.namfcu.net

Page 8: PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone:

Federal Fiscal Year 2012 Investigations – 349 Indictments/charges – 91 Convicted – 150 Civil settlements/Judgments – 44 Recoveries - $124,095,613.00

Total Medicaid Expenditures $7,353,759,981.00

52 MFCU employees

LOUISIANA MFCU

Page 9: PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone:

MEDICAID IS FOR THE

NEEDY --

NOT THE GREEDY!

Page 10: PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone:

• Case Examples• BFSNR• Hospital Overlaps• Worker not present

• False Documentation – DSW and/or Owner• Falsified documents in personnel folder• CPR card• background check

• Other

• Reporting Cases

LOUISIANA MFCU

Page 11: PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone:

Type name and search

Page 12: PREVENTION & PROSECUTION OF MEDICAID FRAUD AND RECIPIENT ABUSE MEDICAID FRAUD CONTROL UNIT Post Office Box 94005 Baton Rouge, Louisiana 70804-9005 Telephone:

TO REPORT FRAUD OR ABUSE CONTACT:

ATTORNEY GENERAL’S MEDICAID FRAUD CONTROL UNIT

1-888-799-6885

Reports may also be made to The Department of Health and Hospitals

(DHH), Local Police, or the Sheriff’s Office


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